Name: The Forensic Examiner Publisher: American College of Forensic Examiners Audience: Professional Format: Magazine/Journal Subject: Health; Law; Science and technology Copyright: COPYRIGHT 2011 American College of Forensic
Examiners ISSN:1084-5569

Issue:

Date: Winter, 2011 Source Volume: 20 Source Issue: 3

Geographic:

Geographic Scope: United States Geographic Code: 1USA United States

Accession Number:

275636302

Full Text:

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INTRODUCTION

Abuse is an issue that all healthcare practitioners must be aware
of. Observation is one of the skills the practitioner must have. When
abuse is reported or suspected, and contusions may be present,
documentation is essential. The practitioner should be familiar with
bruising, causes of bruising including non abuse, if lesions are
consistent with the patient/patients representative's story(ies),
reporting protocols, and available imaging techniques. This work
provides a brief review of the basic information, and explores fairly
inexpensive methods of imaging contusions. The techniques include the
use of infrared digital imaging through cosmetic cover, visible digital
imaging, imaging under the Wood's lamp, imaging with 390 peak
nanometer torch with and without yellow filter, and image enhancement
via digital contrast manipulation. Of the ultraviolet techniques, the
authors found the 390 namometer illumination coupled with the yellow
filter provided more distinct imaging than the 365 peak nanometer
Wood's lamp.

REPORTING LAWS

Many states have mandatory reporting laws (State Statutes Search).
The following are excerpts of the law for the State of Connecticut as an
example: Sections 17a-101 through 17a-103a, inclusive of the Connecticut
General Statutes, "Connecticut law requires certain citizens to
report suspected child abuse and neglect. These mandated reporters are
people in professions or occupations that have contact with children or
whose primary focus is children." "The law requires that they
report suspected child abuse or neglect." "Reporters must
report orally to the Department of Children and Families' (DCF)
Hotline or a law enforcement agency within 12 hours of suspecting that a
child has been abused or neglected and must submit a written report
(DCF-136 form) to DCF within 48 hours of making the oral report. DCF is
required to tape record all reports to the Hotline." (Department of
Children and Families)

According to the Welsh Child Protection Systematic Review Group,
bruises may be suspicious, especially in a non-mobile individual such as
a baby or invalid. Once the individual/child becomes mobile, accidental
bruising becomes more common (Welsch Child Protection 2009; Sugar,
Taylor, and Feldman 1999). Non-accidental bruising is more common to the
head, flesh not covering any bony protuberances, and on the face, back,
buttocks, abdomen, arms, ears and hands. Ninety percent of abused
children exhibit bruising (World Health Organization 2004). A pattern
bruise, for instance, made by a coat hangar, cord, belt, spoon, etc, or
multiple bruises similar in shape and size is suspect. Petechiae are
more common in abuse than in accidental origin (Nayak, et al., 2006).
Marks from gripping, pinching, slapping, biting, or finger imprinting
(around throat) are more often than not associated with abuse, as are
the simultaneous appearance of old and new bruising along and with other
injuries (Merck Manual). Suspicions should be raised when the patient or
the caregiver has no explanation for the injury, the details of the
injury change, the explanation is not consistent with the injury, the
explanation is not consistent with the level of development of the
patient, or different witnesses provide differing accounts (Kellogg
2005).

The clinician should be cognizant of the entities, such as platelet
disorders, coagulation disorders, or defects in blood vessels, which
promote an increase in bleed times, and the potential increased ease of
bruising (Excessive Bleeding). If the area of bruising is out of
proportion to the injury, such possibilities should be considered. These
may include vitamin K (Medline Plus) and vitamin C (Medline Plus)
deficiency, leukemia (Acute Leukemia 2008), von Willebrand disease (Von
Willebrand), Marfan syndrome and connective tissue disorders
(Ehlers-Danlos Syndrome 2008), Henoch-Schlonlein purpura
(Henoch-Schonlein), hemophilia (Hemophilia 2006), cirrhosis (Cirrhosis
2007), hepatitis, liver failure, (Liver Failure), bone marrow disorders,
and qualitative platelet disorder (Low Platelet Count). Pharmaceutical
etiolology include aspirin, non steroidal anti inflammatories (NSAIDS),
platelet inhi bition medicines such as Plavix (clopidogal), coagulopathy
(Coumadin), and cortico steroids (Ballas and Kraut 2008). Senile purpura
occurs with fragility of the capillaries (Senile Purpura 2009).
O'Hare and Eden, 1984, suggest that, "non-accidental injury
and bleeding disorders are in no way mutually exclusive."
(O'Hare and Eden 1984) If found, bleeding disorders must be
addressed, if abuse is found, that situation must be addressed.

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Bruise mechanics/chromophores--Blunt force trauma (BFT) damages
blood vessel/ capillary walls in the epidermis, dermis or subcutaneous
tissues, allowing blood to escape from the vessels into the surrounding
tissues (The skin depth varies on different areas of the body (Moore,
Lunt, McManus, Andersen, and Herrick 2003). This is a bruise or
contusion. The blood appears reddish close to the skin surface, yet
appears blue deeper in the tissues due to Rayleigh scattering (Bohnert,
Baumgarmer, and Pollak S 2000). Initial redness is from the
erythrocytes, and from vessel dilation with the associated inflammatory
process. As the red erythrocytes and hemoglobin are degraded into the
biliverdin chromophore, a greenish hue develops. Further degradation to
bilirubin shifts to yellow/orange (Freeman & Co. 2003). Further
changes in color are to brown with the increase in hemosiderin. The age
of a bruise may be compared to another bruise, but studies reveal that
the accurate assignment of age to bruises is not possible at this time
(Nash 2009). Typical color changes progress from a range of red to blue;
then green, to yellow to brown.

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DETECTION AND IMAGING OF CONTUSIONS

A subclinical bruise detected via infrared or UV may be new or
old--the area should be inspected over time, with careful documentation
made of the size, location, patterns, and changes as they occur. It is
reported that an old bruise may be made apparent via alternative imaging
for months post trauma. (Vogeley and Pierce 2002)

Robert Wood, who developed the Wood's Lamp and Wood's
Glass, was the first to image ultraviolet and infrared with emulsion
photography, exploring invisible radiation photography (Abrahams and
Wood). There are portions of the spectrum existing adjacent to the
visible spectrum, above and below, particularly those with wavelengths
in the near infrared and near ultraviolet, which emit photons the human
eye cannot detect without artificial means. The human range of vision
typically runs from 400 nanometers to 700 nm (Merriam Webster). Filters
and digital imaging allow the human eye to detect emission from these
sources of invisible radiation, and effectively expand the viewing
range, therefore, allowing the visual detection of otherwise unnoticed
formations (Peca Scientific).

The Wood lamp emissions do overlap into the visible spectrum, as do
some UV "forensic" lamps. The Wood's, with a peak
wavelength of 365, emits over the range of 320-400 nanometers (Gupta and
Singhi 2004). When imaging true UV, a digital camera equipped to image
said spectra might employ a visible blocking filter, allowing exposure
of only true UV to the camera sensor (Schneider 2006). Lights and
filters have a peak wavelength, yet allow percentages of adjacent
wavelengths to pass. Some allow a wide range of wavelengths, and some
rather narrow. Wavelength emissions specifics (lamps) and wavelength
passage specifics (filters) are often available from the manufacturer or
supplier (Peca Filter, LED Museum, and Arrowhead Forensics).

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ENHANCING VISIBILITY OF SUBCLINICAL AND CLINICAL BRUISING

Infrared wavelengths penetrate deeper into the skin than
ultraviolet wavelengths (Anderson and Parrish 1981). The authors'
experience demonstrates that a bruise covered with makeup is better
viewed with infrared imaging. Titanium dioxide and zinc oxide are
ingredients often found in cosmetics (FDA VCRP). These compounds do
attenuate the transmission of UVB and UVA. UVA encompasses the emission
of the Wood's lamp and a 390nm light source. A digital camera that
is infrared capable is more convenient than a film camera and infrared
emulsion photography (DeBroux, McCarl, Shimamoto, and Brooks 2009). The
digital infrared camera may be equipped with "live view,"
where the image sensor provides a real time view of the subject (Gupta
and Singhi 2004 Fujifilm 2006). The Olympus IR camera used allows live
view, so the image may be viewed through the video screen, allowing a
view before exposing the shot. Without the live view, the infrared image
would not be visible in the Single Lens Reflex (SLR) camera viewfinder.
Once the exposure is made, the recorded digital image may be
transferred, for instance, to a computer, and viewed in the larger
format often needed to locate bruising. Initial inspection of the
exposure may be reviewed in the digital camera's display screen.

The Wood's lamp has been useful not only in fluorescence of
fluorescein for ocular surface inspection, but additionally for
examination of numerous dermatological conditions and medical
applications (Gupta and Singhi 2004). Visible digital photography
coupled with ultraviolet wavelength illumination is described in
(Vogeley and Pierce 2002). A Wood's lamp is used to reveal and/or
enhance viewing of subclinical and visible bruises with the naked eye. A
digital image of the subject area illuminated by the Wood's lamp
may be transferred to a computer, and enhanced by manipulating the image
contrast, typically by 30-40% to better view the area of interest.

RESULTS

Digital images were procured of the area in question prior to
trauma as seen in Image #1. Figure 82 was captured immediately after the
trauma, induced by several strikes by a rod. Figure #3 was captured
under Wood's Lamp illumination, and Figure #4 is a digitally
enhanced version of Figure #2. Three hours post trauma, Image #5 was
captured, revealing decreased erythema. The tramline contusions are less
apparent. Image #6 was captured under Wood's Lamp illumination, and
Image #7 is the digitally enhanced version of Image #6, with greater
contrast of the tramline markings.

The authors found that bruises are more apparent when illuminated
by an ultraviolet light and viewed through yellow filter goggles (The
authors found that a LED UV lamp, peak wavelength of 390nm, appears to
provide a stronger beam compared to the performance of 3 different
Wood's lamps, peak emission at 365nm, for direct viewing and
imaging of subclinical and apparent bruising). The longer wavelength in
theory should penetrate the skin deeper than the Wood's lamp. This
method appears to be clinically efficient for screening and digital
imaging. Therefore illuminating the area in question with a 390
nanometer LED lamp coupled with applying a yellow (blue-free) barrier
filter to the camera lens provides a prominent appearance of a bruise if
present. Figure #8 was captured under 390 nanometer Light Emitting Diode
lamp, coupled with the yellow camera lens filter. No digital
enhancements were made of the image. The superficial tramline bruises
are apparent, and the deeper underlying roundish bruise is as well.

Makeup was applied over the area of question and captured in Image
#10, and Image #9 is of the bruise area prior to cosmetic cover. Neither
the tramline nor the deeper bruise are apparent under visible or
Wood's Lamp illumination (see Image #11). Image #12 is the area
illuminated with infrared light (720 nanometers) and imaged by an
infrared-capable digital camera. The deeper roundish bruise is apparent
under infrared imaging. Image #13 is of a second bruise, visible
imaging. Image #14 is of the bruise with cosmetic cover. The cosmetic
covered area is imaged with infrared in Image #15 revealing the
underlying bruise, and then enhanced with approximately 40% increase in
contrast seen in Image #16. (Infrared digital imaging reveals bruises
covered with makeup when utilizing the "live view" camera
feature or digital imaging.)

Figure #17 is the contusion area image via Optical Coherence
Tomography as an example of other imaging technology (The OCT used for
this image is designed for ocular use, where dermal OCT imaging would
require a unit capable of deeper tissue penetration). Optical Coherence
Tomography has successfully demonstrated intra-dermal imaging of tattoos
(Todorovic et al., 2008), burns (Morsy, Mogensen, Thrane and Jemec
2007), and other cutaneous manifestations.

DISCUSSION

In summary, a 390 nanometer LED lamp coupled with yellow filter
goggles allows sub clinical bruise and enhanced clinical bruise viewing.
The same 390nm light source with a yellow camera lens filter allows
digital imaging, typically not requiring digital enhancement to reveal
the contusion. The 390nm light source with the yellow filter appears
superior to the Wood lamp technique, and superior to the Wood's
lamp technique with digital image enhancement. Infrared imaging allows
deeper bruises to be viewed, either through the camera video screen or
from digital photographs. Additionally, infrared imaging allows viewing
of bruising through applied makeup. The Wood's Lamp is useful for
viewing non-clinical bruising, and in enhancing visible bruising, but is
not as sensitive as the 390 nm light source coupled with the yellow
filter. The authors would recommend that it would be desirable to have
available a 390nm torch/yellow filter goggle combination for direct
viewing and yellow camera filter for digital imaging/documentation of
contusions, apparent and subclinical. Additionally, an infrared digital
camera would provide useful for situations of detection and
documentation of bruising beneath cosmetic cover.

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REVIEW of ABUSE

The CAPTA (Child Abuse Prevention Treatment Act) defines child
abuse as "Any recent act or failure to act on the part of a parent
or caretaker, which results in death, serious physical or emotional
harm, sexual abuse, or exploitation, or an act or failure to act which
presents an imminent risk of serious harm" ("Child
Welfare" 2007)

According To the NCANDS (National Child Abuse and Neglect Data
System):

* In the year 2007, there were 294,000 child abuse cases reported,
of which 10:8% involved physical harm.

* Of the victims, slightly more than half were female. Ethnicity
was reported as 46.1% Caucasian, 21.7% African-American, and 20.8%
Hispanic.

* Abuse is not limited to children. Elder abuse and intimate
partner abuse is another area of concern. (CDC 2006, CDC 2009, CDC 2003)

* A study (Forensic Nursing vol. 5) included information regarding
injuries of non-accidental childhood fatalities, grouped by age.
Cutaneous contusions, mostly including the areas of head, face, mouth,
and also commonly the buttocks and upper arms were common for the listed
groups.

CERTIFIED MEDICAL INVESTIGATOR (CMI)

Check out the Certified Medical Investigator program for a more
in-depth look at the field of medical investigation, which will examine
the main forensic disciplines, crime scene basics, and proper
identification of various kinds of abuse and causes of death. Enroll
online today at www.acfei.com, or call (800) 423-9737 for more
information.

DR E ROBERT BERTOLLI, an optometric physician, is a Life Fellow of
the American College of Forensic Examiners and director of its forensic
optometry division. He is an Adjunct Speaker at the Connecticut Police
Training Academy (Police Officers Standards and Training) for medical
aspects of horizontal gaze nystagmus and vision science for impaired
driving enforcement; is on several boards including the Board of
Directors of the Connecticut Association of Optometrists; board of
directors of American Board for Certification in Homeland Security;
editorial board of the Forensic Examiner; vice chair, board of directors
of the American Board for Law Enforcement Experts; editorial board for
Inside Homeland Security, former vice chair of the American Board of
Forensic Examiners. He is in optometric practice in Connecticut, and
studied behavioral optometry under Dr. Constantine "Gus"
Forkiotis.

CLIFFORD D. BROWN has spent 17 years in the senior ranks of the
Public Health Service, three years at the US Air Force Goodfellow Field
(Security Services/Cryptology training base) during Viet Nam, and four
years in the US Army (during Desert Shield/ Desert Storm). Having been
through the Air Force Officer Basic Course, the Army Officer advanced
Course, the Army Combined Arms Staff Services School, and functioned as
the Deputy Chief of Eye Care and periodically as the Administrative
Officer in the 2000 bed Frankfurt Army regional Medical Center.

Within the field of primary and specialty care he has provided
diagnosis and treatment of ocular pathology and the provision of service
with a strong public health orientation. To this end he was the first
PHS officer to successfully gain Diplomate status in the American
Academy of Optometry's (AAO) Public Health and Environmental Vision
Section (the international scientific and vision research organization),
an accomplishment requiring years of testing and research.

The Montana Governor appointed him to serve on his TBI Advisory
Board, the MTTBI Association Board of Directors, and as a founding
member of the Montana State Traumatic Brain Injury Association.

DR. PANNONE is a behavioral optometrist who has been practicing in
Norwich Ct. since 1960. Received B.S. from U.R.I.1953, B.S. O.D. from
Mass. College of Optometry 1958 (Beta Sigma Kappa). Studied at Gesell
Institute of Child Development 1969 and today deals with children's
vision and learning problems. He is a member of American Optometric
Association, and for 35 years Optometric Extension Program. He
established the vision care and health section for the Haitian Health
Foundation, Jeremie, Haiti in 1989 and still serves as its'
consultant. In 1990 he became a Connecticut State Police Surgeon and
today is an adjunct lecturer at the Connecticut Police Academy on
Vision, Drugs and Alcohol and their effects on driving. He is a member
of the American College of Forensic Examiners International, and is a
Certified Medical Investigator level 5. He has lectured at the ACFEI
2004 national conference on Forensic Optometry. He is a Police Surgeon
for the Amtrak Police Department Fraternal Order of Police #189, a
member of the Citizens Police academy Troop E, Montville Ct. and has
guest lectured on Drugs Alcohol and Driving. He has been a co- author on
many peer reviewed articles. Dr. Pannone is a member of the DRE section
of the IACP.

THADDEUS W. BARTLES, OD is Academic Chairman for the Connecticut
Association of Optometrists. He was named Optometrist of the Year in
2010 and received the President's Award in 2008. He has been in
private practice in Bristol, CT since graduating from the Massachusetts
College of Optometry in 1974. Dr. Bartles belongs to the American
Optometric Association. He is a frequent visitor to area schools and
libraries, and has appeared on "The Doctor is In," a
production of Nutmeg TV. In his spare time he plays clarinet in a
classical wind ensemble and guitar in a rock band.